Refeeding Syndrome

Joanna Prickett North Bristol NHS Trust

Definition

Severe fluid and electrolyte shifts and related metabolic complications in malnourished patients undergoing refeeding.

Consequences of Starvation
Decreased insulin and increased glucagon secretion. With a switch from glucose towards ketone bodies as a source of energy Glycogen stores used BMR decreases Brain adapts to using ketones Atrophy of all organs Reduced Lean Body Mass Abnormal liver function

Consequences of starvation
Deficiency of vitamins and trace elements Whole body depletion of potassium, magnesium and phosphate Increased intracellular and whole body sodium and water Impaired cardiac, intestinal and renal reserve, leading to reduced ability to excrete excess sodium and water Serum concentrations of electrolytes maintained within normal limits

Refeeding
Increased insulin release leads to increased uptake of glucose, phosphate and potassium into cells. Magnesium is used as a co-factor for cellular pump activity Reactivation of the Na/K membrane pump leads to further movement of K into cells with a simultaneous movement of sodium and fluid out of cells

Refeeding
Reduced phosphate is associated with increased urinary magnesium excretion Stimulation of protein synthesis leads to increased anabolic tissue growth which in turn leads to increased cellular demand for phosphate, potassium, glucose and water

Refeeding
Excess glucose can lead to hyperglycaemia and fat abnormalities Reduced sodium and water excretion Increased cellular thiamine utilisation due to its role as a co-factor for carbohydrate metabolism

Consequences of electrolyte abnormalities

Electrolytes PO4 Consequence Acute ventilatory failure Arrythmias Confusion Congesive heart failure Lethargy, weakness Rhabdomyolysis Arrythmias Cardiac arrest Constipation / ileus Polyuria / polydipsia Respiratory depression W eakness Anorexia Arrythmias Confusion Diarrhoea / constipation W eakness

+ K

4 + Mg

Incidence
0.2-5% hospital patients have hypophosphataemia Incidence is increased in certain groups Incidence in patients receiving nutrition support has been reported to be 30-40%

Patients at Risk of Refeeding

Those who have had very little or no food intake for >5 days especially if already undernourished (BMI <20 kg/m2, unintentional weight loss >5% within the last 3-6 months)

Patients at High Risk of Refeeding

Patients with any of the following: BMI < 16 kg/m2 Unintentional weight loss >15% within the last 3-6 months Very little or no nutrition for >10 days Low levels of potassium, magnesium or phosphate prior to feeding

Patients at High Risk of Refeeding

Patients with 2 or more of the following: BMI < 18.5 kg/m2 Unintentional weight loss >10% within the last 3-6 months Very little or no nutrition for >5 days A history or alcohol abuse or some drugs including insulin, chemotherapy, antacids or diuretics

Feeding patients who are at risk

Introduce feeding at maximum 50% of total energy requirements for the first 2 days before increasing to full requirements if no biochemical abnormalities Meet full requirements for fluid, electrolytes, vitamins and minerals from day 1 of feeding Monitor appropriate biochemistry including potassium, phosphate and magnesium (see chapter on monitoring)

Feeding patients who are at high risk

Consider starting nutrition at maximum 10 kcal/kg and increase slowly to meet full requirements by 4-7 days. Any increase in feed should be dependent on trends in biochemistry

Feeding patients who are at high risk

Potassium, magnesium and phosphate supplementation from the outset (unless blood levels are already high): Potassium (likely requirement 2-4 mmol/kg/day) Magnesium (likely requirement 0.2 mmol/kg/day IV, 0.4 mmol/kg/day oral) Phosphate (likely requirement 0.3-0.6 mmol/kg/day)

Feeding patients who are at high risk

Immediately before and during first 10 days of feeding: Oral thiamine 200-300mg/day Vitamin B co strong 1-2 tds or full dose IV vitamin

B Multivitamin and trace element supplement Restore circulatory volume and monitor fluid balance closely

Monitor appropriate biochemistry including, potassium, phosphate and magnesium

Feeding patients who are at high risk

In extreme case eg BMI<14 kg/m2 Very little or no nutrition for > 15 days Pre-feeding Hypokalaemia, hypophosphataemia or hypomagnesaemia Consider starting feed at 5kcal/kg

It is not necessary to correct electrolyte levels prior to feeding if this cautious approach is used

Feeding patients who are at high risk

Beware of very malnourished, dehydrated patients with renal impairment and consequently normal or high potassium and phosphate levels. It is also easy to overlook significant renal impairment in patients with very low BMI and recent starvation who have very low creatinine and urea production.

References
Brook M.J. & Melnik G 1995. The Refeeding Syndrome: An approach to understanding its complications and preventing it occurrence. Pharmacotherapy 15(6):713-26. Crook M.A. et al 2001. The importance of the Refeeding Syndrome. Nutrition 17:632-7. Keys A. et al 1950. The Biology of Human Starvation vols 1,2. Minneapolis University of Minnesota Press. Marinella M.A. 2003. The Refeeding Syndrome and Hypophosphataemia. Nutrition Reviews 61(9):320-3. NICE 2006 Nutrition Support in Adults Solomon S.L. et al 1990 The Refeeding Syndrome: A Review. J. Parent. & Enteral Nutrition 14(1):90-7. Terelevich A. et al 2003. Refeeding Syndrome: Effective and safe treatment with phosphates polyfusor. Aliment. Pharmacol. Ther. 17:1325-1329.